‘It’s not just about the dinner; it’s about everything else that we do’: A qualitative study exploring how Meals on Wheels meet the needs of self‐isolating adults during COVID‐19

Abstract Meals on Wheels (MoWs), a service offered by local authorities in England, deliver meals to older, housebound and/or vulnerable adults, who might otherwise not be able to acquire and prepare their own meals. Research suggests that MoWs provide benefits beyond nutrition. Little is known about the actual interactions between service providers and clients, particularly during the COVID‐19 pandemic. The aim of this small‐scale, formative study was to explore MoWs service providers’ experiences and their perceptions around the benefits and challenges faced by the service, and understand how these experiences changed during the first UK national lockdown. Semi‐structured interviews were conducted in September 2020 with 18 service providers of MoWs (drivers who deliver the meals, service coordinators and managers) in two local authorities in England, and analysed thematically. Participants indicated that benefits of the service encompassed those to clients (e.g. welfare checks, encouraging independence and identifying and addressing isolation and loneliness), employees (e.g. sense of pride, rewarding relationships with clients) and the wider community (e.g. reducing pressures on families), and described MoWs as the ‘fourth emergency service’ (e.g. being the first responders to emergency situations). Participants identified several challenges faced by the MoWs service, including organisational challenges (e.g. funding cuts and closures, lack of appropriate publicity to raise awareness of the service) and restrictions on time spent with clients. The pandemic and lockdown resulted in increased demand on resources, concerns about client and staff wellbeing and uncertainty about how the service will cope if lockdowns continue. These findings provide important insights regarding the wide benefits of MoWs and the challenges the service faces, which can be used as the formative research base to guide future interventions and policies to protect vulnerable adults, not only during the COVID‐19 pandemic, but beyond.


| INTRODUC TI ON
In March 2020, an estimated 1.5 million people most vulnerable to COVID-19 were instructed to shield in England. A further 17.7 million adults aged ≥70 years were instructed to stay at home as much as possible, as they were considered to be at increased risk of infection (UK Cabinet Office, 2020). Many of these individuals might not have had sufficient support from families and community resources to access adequate and nutritious food, nor the financial resources or capability to prepare their own meals. These factors are established as contributing to undernutrition in older adults who are housebound (Locher et al., 2008). Coupled with the fact that approximately one in seven adults aged ≥65 years is at medium or high risk of malnutrition (BAPEN, 2018), the need for all vulnerable individuals to access nutritious food during the pandemic became imperative.
Meals on Wheels (MoWs), as a service offered by 42% of local authorities across the United Kingdom (UK) (National Association of Care Catering, 2018), might be crucial in delivering food to housebound adults. Consistent evidence suggests that MoWs improve nutrient intakes in older adults (Wright et al., 2015;Zhu & An, 2013) and offer benefits that extend beyond nutrition, including the provision of welfare checks, opportunities for social interaction, decreased rates of isolation and improved quality of life (Campbell et al., 2015;Thomas et al., 2016). The use of MoWs has also been linked to decreased need for residential care, by helping vulnerable individuals remain independent in their homes and communities and 'age in place' (Altshuler & Schimmel, 2010;Thomas & Mor, 2013).
These beneficial outcomes present essential preventative measures, and would undoubtedly have become more important during the pandemic, which increased demand for the service in the UK (Sustain, 2020).
A recent qualitative study in the United States of America (USA) that explored the perceptions of MoWs drivers about their interactions with clients confirmed many of the aforementioned benefits (Thomas et al., 2020). Much of the research on the benefits of MoWs, however, comes from the USA and Canada (Winterton et al., 2013), and therefore might not be generalisable to the UK. No research to date has examined the perceptions of MoWs service providers in England, particularly with regards to the benefits of MoWs and the challenges faced by the service.
Further, no study has explored how these experiences changed during the first national UK lockdown (March-June 2020). The aim of this study was therefore to explore these issues among drivers who deliver the meals, service coordinators and managers in two local authorities (LAs) in South-West England. The study was funded as part of an initiative to provide evidence to inform policy actions for protecting the most vulnerable (Papadaki et al., 2021), particularly during the pandemic. Findings from this small-scale, local study contribute to the evidence base informing future interventions and policies aiming to enhance the MoWs service.

| Study design and participants
Semi-structured interviews were conducted in September 2020 with employees of MoWs services in two LAs in South-West England, which were conveniently and purposively selected according to geographic location (urban and semi-urban). MoWs managers in the two LAs were invited by email to act as gatekeepers for participant recruitment. This involved circulating a study invitation to all MoWs employees who engage directly with clients (n = 23 and n = 20, in the LAs serving urban only and semi-urban areas, respectively). A total of 19 employees initially expressed interest in participating.
Of these, one was not available for an interview; the remaining 18 employees participated. Data collection and analysis proceeded in parallel and saturation was deemed to have been reached after the sixteenth interview (Harris et al., 2009). The study is reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong et al., 2007) (Table S1).

| Data collection
Semi-structured interviews, lasting 28-56 min, were conducted via telephone and audio recorded. Two interview guides were developed to explore the experiences of MoWs drivers, and What is known about this topic?
• Meals on Wheels (MoWs) provide meals to vulnerable individuals who might not be able to prepare or acquire their own meals.
• MoWs provide wider benefits in addition to improving nutritional intakes.
• No study has examined the staff-client interactions, benefits and challenges faced by MoWs in England, or how experiences with service provision changed during the COVID-19 pandemic.

What does this paper add?
• MoWs offer multiple benefits to clients, employees and the wider community.
• MoWs experience many challenges, such as funding cuts and closures, lack of appropriate publicity and reduced time spent with clients.
• Further challenges introduced by the pandemic included an increased demand on resources and concerns about client and staff wellbeing and how the service will cope if lockdowns continue. employees with office-based duties (Appendix S1-S2). The guides were not piloted, but were informed by recent research exploring the interactions between MoWs drivers and clients in the USA (Thomas et al., 2020), and developed further to explore topics that addressed the specific objectives of the current research.
In summary, the interviews explored participants' experiences working within the service and delivering meals to clients, their perceptions on the benefits of MoWs to older adults, and the challenges they faced in their job and those faced by the service more generally. Participants were also asked to describe a typical meal delivery interaction and to discuss whether they offer any other assistance to their clients, apart from delivering the meals. The interviews also facilitated the exploration of whether participants' experiences with clients and delivering the service might have changed during the first national UK lockdown, and their perceptions of the implications that a new wave of infections might have on them personally, their clients, and the MoWs service more generally.
All interviews were conducted by the second author, an experienced qualitative researcher. No prior relationship had been established between the interviewer and participants. Participants were asked to report their role, and how many years they had been working for the service. Notes were kept during the interview to help probe for more information and verify responses at transcription.
At the end of the interviews, a summary of main points was provided to participants, which helped to confirm accuracy of responses (Korstjens & Moser, 2018). Interviews were transcribed verbatim and anonymised; transcripts were compared with recordings and field notes to verify credibility.

| Data analysis
Data were analysed thematically (Braun & Clarke, 2006). The second author read through the 18 transcripts and coded them inductively, which involved initial coding of the data into broad codes. This was followed by a process of secondary coding, where data were analysed line-by-line to create specific codes. The fifth author independently coded 30% of the transcripts (n = 5) to ensure rigour of the coding process (Korstjens & Moser, 2018). Any discrepancies were discussed, after which the coding process was refined; the second author then coded all transcripts using this codebook. Any new codes were noted, discrepancies were discussed and the codebook was refined. The codes were organised into themes and sub-themes, and further reviewed by the team to ensure coherence within and across themes (Elliott, 2018).
NVivo software (version 12.0, QSR, Southport, UK, 2018) was used to facilitate the coding. Themes and sub-themes are illustrated with representative quotations from participants (indicated as P1-P18 and driver (D)/office-based role (O)). Additional quotations are provided in Table S2.

| Ethical considerations
The study was approved by the School for Policy Studies Research Ethics Committee at the University of Bristol  and complied with the European General Data Protection Regulation.
Participation was voluntary. Participants were provided with an information sheet describing the aims and processes of the study, provided written informed consent prior to interviews and received a £10 gift voucher as a token of appreciation.

| FINDING S
Interviews were conducted with 18 MoWs employees (Table 1) ing and interaction bit (P11/D). As part of these checks, participants checked for safety concerns and household hazards, including trip hazards, whether the heating works, checking the fridge for old food and checking for gas leaks. In addition, participants from one LA had received training in medication prompting and therefore prompted clients to take their medication. However, participants in the other LA acknowledged this is a service they are unable to provide without receiving the appropriate training. Overall, welfare checks were considered 'little things to us, but they are … vital to them' (P3/D).

| Identifying, addressing and reducing isolation and loneliness
Social interaction is also an important part of the MoWs service and a way to identify, address and reduce isolation and loneliness in clients, as it helps with 'taking the anxiety levels down a notch' (P18/D).
Social interaction was deemed particularly important during lockdown; participants reported that their clients were feeling extremely lonely as they were not being visited by family members 'because of the fear of COVID and passing it on' (P1/D). This participant also highlighted that for some clients, they are the only person they see on any given day. You go in there and you see their faces light up… they are absolutely delighted to see you… because you might be the only person that they see daily (P1/D). As a result, and in response to each TA B L E 2 Themes and sub-themes resulting from the thematic analysis

This study exploring the experiences of MoWs employees in two
English LAs highlights the wider benefits of the service, with participants drawing attention to the emergency response the service entails to ensure clients' wellbeing. Participants provided important insights on the challenges they encounter, including COVID-specific challenges, and those that the service faces more widely. These findings add to the limited global literature around the benefits and challenges of MoWs, and shape a crucial formative research evidence base for the development of interventions and policies aiming to support vulnerable individuals, particularly during continuing lockdowns, but also beyond the COVID-19 pandemic.
Participants reported that MoWs bring a variety of benefits to clients that extend beyond nutrition. These include carrying out chores and welfare checks for clients. This is in agreement with a US study, which found that MoWs drivers perform essential tasks around clients' homes, raise attention to potential hazards and conduct safety checks (Thomas et al., 2020). Other studies have highlighted the role of MoWs in reducing isolation and loneliness, as well as in promoting independence and decreasing the need for residential care and healthcare costs, which was confirmed by the current findings (Thomas et al., 2016;Thomas & Mor, 2013). Of note, participants in the current study mentioned that for some clients, MoWs drivers are the only people they see on any given day. The benefits of social interaction that MoWs clients receive have also been reported in earlier studies (Grant & Jewell, 2004;Timonen & O'Dwyer, 2010).
As housebound individuals are likely to report depressive symptoms (Sirey et al., 2008), these findings suggest that MoWs are an important community resource to reduce social isolation of housebound vulnerable individuals.
A unique finding of the current study was that some drivers encouraged their clients to move more, even though promoting physical activity is not part of the service's remit. Considering that physical activity among housebound individuals is challenging (Szanton et al., 2016), MoWs could serve as an important community intervention to promote movement in this population, with careful planning to account for clients' individual circumstances. In addition, only those participants who had received training in medication prompting were allowed to remind their clients to take their medications.
Expanding this training for all LAs offering MoWs might provide a crucial lifeline for clients with cognitive decline, who are a considerable proportion of MoWs recipients (Altshuler & Schimmel, 2010;Xu et al., 2010). Further, we found that MoWs drivers are often the first responders in emergencies, which supports research among recipients of MoWs in Ireland (Timonen & O'Dwyer, 2010). Another unique finding of the current study is that the MoWs service collaborates with emergency and social services to ensure that vulnerable clients are cared for. The service also goes 'above and beyond' to continue delivering meals in adverse circumstances, such as during periods of extreme weather and the COVID-19 pandemic, suggesting its crucial role in protecting the most vulnerable.
Our findings regarding the benefits of MoWs on employees themselves add to the limited evidence base and corroborate those of a US qualitative study (Thomas et al., 2020). We found that working in this service exerts a sense of pride for giving something back to the community. Participants also described the development of reciprocal and caring relationships with their clients, which are equally rewarding to themselves as to their clients. Even though all participants in the current study were paid employees, these findings are important for other MoWs settings globally that rely heavily on volunteers; the reported perceived benefits of working for the service should be highlighted to incentivise recruitment and raise awareness that this role involves more than just delivering a meal.
Several challenges faced by MoWs emerged from the current study. Participants highlighted that there are ongoing concerns about budget cuts and service closures, which would be particularly concerning if an increasingly ageing population led to significant service demand (Campbell et al., 2015). This is particularly significant, given that a variety of ageing and environmental factors, including physical challenges, difficulties around food consumption and access and use of transport are common in older adults, and identified as contributing to their need for food assistance (Lee et al., 2005a;Warren et al., 2020).
Despite their projected benefits in reducing healthcare and long-term care costs (Meals on Wheels America, 2020; Thomas & Mor, 2013), MoWs are suffering budget cuts globally, or do not receive sufficient funding to keep up with the need for the service; this hinders their ability to deliver community services to the most vulnerable and their capacity to respond to increased service demand (Gualtieri et al., 2018;Winterton et al., 2013). Our study adds to these findings by showing that this was particularly the case during the lockdown, when demand increased and having sufficient human resources was often a challenge. Even though outsourcing of administrative duties can form part of successful MoW delivery models and might relieve budget and human resource pressures that LAs face (Winterton et al., 2013), our findings draw attention to potential pitfalls of outsourced administrations. Notably, there was a concern about outsourced teams lacking awareness of the local context and the specific circumstances of clients, which might contribute to MoWs drivers feeling less supported to carry out their role. Also, keeping the administration and delivery of MoWs 'in-house' seemed to facilitate a rapid and coordinated response in emergency situations, between all the services that might be needed to ensure a client's wellbeing. This finding should be studied further, but it indicates the importance of keeping the service local. The current study also highlighted that MoWs do not receive sufficient publicity in England, hindering awareness of the service among people who might need it the most. This supports findings from an earlier US study among providers of nutrition programmes for older adults, which identified that misconceptions and lack of awareness of such programmes are important challenges to outreach and meeting the needs of individuals who live in the community and are in need of care and support (Lee et al., 2005c). It is therefore important to raise awareness of the existence of MoWs and the service's wider preventative value via appropriate framing of publicity resources (Papadaki et al., 2021).
It is noteworthy that participants in the current study raised concerns about how time available with each client is restricted, and had reduced further during the pandemic. Having sufficient time to interact with clients beyond the meal delivery itself is an important element of the service's social nature and is crucial to carry out welfare checks (Winterton et al., 2013). Earlier research has demonstrated the challenges that time pressures place on the amount and quality of social interaction MoWs clients experience (Frongillo et al., 2010;Timonen & O'Dwyer, 2010). Despite the rewarding nature of the job, participants reported many challenging situations they encounter daily that can have a negative impact on their mental health. The need to support MoWs employees' wellbeing is therefore crucial so that they continue providing this important service (Papadaki et al., 2021).

| Implications for practice and policy
Despite the small-scale, exploratory nature of this study, our find-  Ireland) to obtain more representative views and experiences. In addition, the sample size was relatively small, and we cannot exclude the possibility of self-selection bias. However, the study took place while COVID-19 restrictions were in place, which might have made it challenging for employees with competing priorities to participate.

| CON CLUS IONS
This small-scale study highlights the wider benefits of MoWs and the ongoing challenges services face. It also highlights unique challenges introduced by the COVID-19 pandemic, which might hinder the service's performance and beneficial outcomes in a combined situation of continuing lockdowns, increased number of individuals needing to self-isolate, and insufficient financial support to meet the demand.
Due to the aforementioned limitations, our findings are exploratory in nature; nevertheless, they suggest that health and social care national policies should prioritise the revival, re-introduction and enhancement of MoWs, by supporting LAs to meet increased demand, particularly during the pandemic. These recommendations will help ensure that the most vulnerable individuals in the community continue to be supported, not only during the pandemic, but beyond.

ACK N OWLED G EM ENTS
We would like to thank Mr James Dagnall, Ms Sarah Shaw and Ms Elaine Kingsley, who facilitated recruitment in the participating local authorities, and all participants for sharing their experiences with us.

CO N FLI C T S O F I NTE R E S T
The authors declare no conflicts of interest relevant to this study.

AUTH O R CO NTR I B UTI O N S
AP conceived the study, with input from PW, KST, AC and MA; KST and EAG contributed to the study design; BA collected the data; BA, AP and PI analysed the data, with input from all co-authors; AP led the drafting of the manuscript. All authors provided critical input, reviewed the manuscript for important content, take responsibility for the contents of this article and approved the final version submitted for publication.

E TH I C S I N FO R M ATI O N
The study was approved by the University of Bristol, School for Policy Studies Research Ethics Committee (SPSREC/19-20/115).

DATA AVA I L A B I L I T Y S TAT E M E N T
The interview guides used to collect data, as well as processed data, are available in the supplementary material of this article. Other data that support the findings of this study are available from the corresponding author upon reasonable request.